What Would They Say Today?

Eighteen months after the terrorist attacks of 9as all U.S. Air Force missile launch facilities, are
11, America's healthcare leadership announced thatlocated in rural areas and are potential targets for
while they had not been ready on September 11,attack. Additionally, if individuals with infectious
2001, now they were. On March 13, 2003, in adiseases, such as smallpox, enter the country
much ballyhooed statement, still sited to this day,through Canadian or Mexican borders, rural
the American College of Healthcare Executivesproviders may be the first to identify the threat."
announced:A Problem of Their Own Making
"HOSPITAL CEOs SAY BIOTERRORISM PLANSThe greatest indictment of hospitals by the
ARE IN PLACE CHICAGOInstitute of Medicine Reports however dealt with
Since September 11, 2001, hospitals have faceddisaster preparedness training and drills finding
new challenges protecting and caring for theirgreat variability in the training of even key
communities, especially the threat of bioterrorism.healthcare personnel with even less training for
According to a new survey conducted by thenon-clinical hospital staff.
American College of Healthcare Executives"Serious clinical and operational deficiencies,
(ACHE), 84 percent of hospital CEOs agree thatfragmentation, and lack of standardization exist
since 9/11, their hospitals have worked moreacross a broad spectrum of key professional
closely with public agencies (e.g. fire, police, andpersonnel (nurses, physicians, ancillary care
public health departments). Further, 95 percent ofproviders, administrators, and public health officials)
the respondents said their hospitals already have,in both individual training and coordination of a
or within six months will have, a bioterrorismteam response."
disaster plan in place, developed in coordinationThis failure to provide training not only effects
with local emergency or health agencies."patient care, but hospital employee safety.
Little did they know the sense of false securityDespite public statements by hospitals that
and the cooling of momentum this assertion would"safety is worth the cost" and "preparedness is
cause from that day forward.priceless" The American College of Emergency
The Clear View of RealityPhysicians (ACEP) and the Agency for Healthcare
Since 2003, multiple independent evaluations ofQuality and Research (AHQR) separately found a
hospital preparedness and hospital disaster planningvery different financial and leadership commitment
have found the reality in each successive year toto preparedness and training.
be far below that purported in 2003. A brief"Many hospitals report inadequate funding to
survey three reports by the Institutes of Medicinecover the attendance costs (e.g., time off, tuition,
in June, 2006 serve as proof that any hint oftravel) of training (ACEP, 2001). At the University
hospital preparedness is false and that momentumof Pittsburgh Medical Center, a disaster drill in the
towards preparedness has been lost. TheseEmergency Department costs $3,000 per hour in
reports, Hospital-Based Emergency Care: At thestaff salaries alone (AHRQ, 2004)."
Breaking Point, Emergency Care for Children:"Additionally, the failure of hospital administrators
Growing Pains, and Emergency Medical Services ator Emergency Department personnel to recognize
the Crossroads found a disparity between selfthe importance of training can result in a lack of
reported preparedness on multiple association andsupport (ACEP, 2001)."
government surveys compared to actualMultiple agencies, including the Institutes of
preparedness measured across the five coreMedicine have called for an increased coordinated
indicators of hospital preparedness.financial commitment to preparedness on the part
"Evaluations of ED disaster preparednessof individual hospitals, hospital corporations, hospital
consistently yield the same finding: EDs are bettermanagement / holding companies, as well as local,
prepared than they used to be, but still fall shortstate and federal governments.
of where they should be""This lack of coordination is reflected in the
At first blush, this seems to confirm the ACHEhaphazard funding of preparedness initiatives. EMS
assertions, but the report goes on to point outand trauma systems have consistently been
that hospitals lack patient surge capacity due tounderfunded relative to their presence and role in
cost related downsizing, nursing shortages, loss ofthe field."
specialists, physical space constrains and"States and communities should play an important
overcrowding. Failures of planning and coordinationrole in determining how they will prepare for
were also identified and linked to erroneousemergencies. To the extent that they are
planning assumptions.supported in this effort through federal
"When a disaster occurs, the normal operatingpreparedness grants, the critical role and
assumptions about patients, responses, andvulnerabilities of hospitals must be more widely
treatments often must be jettisoned. Dependingacknowledged, and the particular needs of
on the type of event, some of the nonroutinehospitals and hospital personnel must be taken
things that can happen include the following:explicitly into account"
· Victims who are less injured and mobileDespite this, funding for preparedness has
will often self-transport to the nearest hospitals,decreased across the board including congressional
quickly overwhelming those facilities.cuts in healthcare preparedness funding for 2007,
· Casualties are likely to bypass on-site2008 and again for 2009. These cuts have been
triage, first aid, and decontamination stations.mirrored in state funding initiatives; meanwhile
· EMS responders will often self-dispatch.hospitals continue to believe that they are
Providers from other jurisdictions may appear atprepared despite evidence to the contrary.
the scene and transport patients, sometimesSo What Should They Say Today?
without coordination or communication with localGiven these realities leaders in the field of
officials.healthcare and hospital management must now
· In some cases, local facilities are notconfront the fact that self reporting on
aware of the event until or just before patientspreparedness is a failed method, no different than
start arriving. Hospitals may receive no advanceasking a 10 year old to grade their own final
notice of the extent of the event or the numbersexam. With the curtain pulled back it is time for
and types of patients they can expect.healthcare and hospitals to say:
· There may be little or no communication"It is our corporate and personal responsibility to
among regional hospitals, incident commanders,ensure the safety and preparedness of our entire
public safety, and EMS responders to coordinatestaff, clinical and non-clinical as well as prepare to
the response region wide."respond to the needs of the patients we serve
The Institute of Medicine reports goes on to callevery day and the patients we will serve when
for improved communications and integrationdisaster strikes."
across disaster response services includingThe problem is that healthcare and hospital
Emergency Medical Services (EMS), communityleaders have done everything in their power to
emergency operations and most importantly thequietly avoid the need to make this statement
implementation of the standardized Incidentmuch less bring this statement into reality. In the
Command System.two years since the Institutes of Medicine
"To respond effectively, hospitals must interfacepublished their reports, hospitals have lobbied first
with incident command at multiple levels and beto delay and forestall the deadlines for both Joint
prepared to deal with transitions between levels,Commission preparedness guidelines and National
for example, when incident command shifts fromIncident Management System (NIMS) compliance
the local to the state or federal level. Each hospitalelements. The effect of this has been to make
should be familiar with the local office ofsuch things as facility beautification a higher
emergency preparedness and know how hospitalsfinancial priority than facility preparedness.
are represented at the emergency operationsWhat is Needed?
center during an event, whether through theWhile the Institutes of Medicine and many other
hospital association, the health department, theorganizations have made recommendations to
EMS system, or some other mechanism."improve hospital disaster preparedness, the sad
They Didn't Think of That Eitherfact is that the only way to force hospitals to
Beyond the problems common to all disaster careproperly and adequately prepare is to enforce the
environments, special needs populations (children,existing guidelines, mandate meaningful external
elderly, mentally and physically challenged) havecertification of compliance and engage the public in
needs and preparedness issues unique to them.demanding local hospitals "just do it." There is an
Unfortunately, the "one size fits none" approachold adage in healthcare law:
taken by America's hospitals has ignored issues"No change in healthcare has ever come without
highlighted by the Institutes of Medicineregulation, legislation or litigation."
Emergency Care for Children: Growing PainsEnforcement of existing guidelines will require that
report.the applicable government agencies including the
"The needs of children have traditionally beenDepartment of Homeland Security, FEMA, the
overlooked in disaster planning. Historically, theDepartment of Justice, the Department of Health
military was considered the only target ofand Human Services and the Center for Medicare
potential biological, chemical, and radiologicalServices mandate full and complete NIMS
attacks, so the focus for training, equipment, andcompliance by the original September 30, 2008
facilities was on the care of healthy young adults."deadline. Further, these agencies must be willing to
"Younger patients require specialized equipmentuse the full force of law to induce hospitals to
and different approaches to treatment in theinvest in preparedness rather than pianos and
event of a disaster. Children cannot be properlyfountains. Federal preparedness legislation carries
decontaminated in adult decontamination unitswith it implications of Medicare fraud,
because they require adjustments to the waterSarbanes-Oxley violations and federal false claims
temperature and pressure (heated, high-volume,issues. It is an unfortunate reality that
low-pressure water). Rescuers also need to havegovernment must all too often prosecute to
child-size clothing on-hand for use after thecreate compliance.
decontamination."The private sector has a responsibility to enforce
The problems are compounded for rural hospitals.preparedness guidelines as well. Joint Commission
Despite the fact that many both inside andhas repeatedly chosen to "partner with hospitals"
outside hospital leadership believe that ruralrather than "punish" the recalcitrant faculties who
hospitals are at lower risk and thus require lessrepeatedly delay and curtail preparedness efforts.
commitment to preparedness, the truth is quiteJoint Commission accreditation is a powerful force
the opposite.for change in hospital healthcare. The current
"The focus of emergency preparedness has beentendency of hospitals to do as little as possible as
on urban areas in part because of the perceivedslowly as possible necessitates that Joint
increased risk of terrorism in these areas.Commission enforce the original preparedness
However, there is a danger associated withcompliance deadline in January of 2009 rather than
neglecting rural areas. Indeed, one might arguepermitting yet another extension.
that rural areas may be even more vulnerable toPerhaps the best thing everyone in healthcare
a terrorist attack. Many nuclear power facilities,oversight and leadership can say to the American
hydroelectric dams, uranium and plutonium storagepeople is:
facilities, and agricultural chemical facilities, as well"We're Sorry and We Will Do Better!